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Radiation Enteritis

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    The diagnosis of chronic radiation enteritis may be difficult to make. Clinically and radiologically recurrent tumor needs to be ruled out. Because of the possible latency of the illness, it is essential that the physician obtain a detailed history of the patient's radiation therapy course. It is often advisable to include the radiation therapy physician in the continued management of the patient's care.

    Treatment

    Medical management of the patient's symptoms (which are similar to symptoms of acute radiation enteritis) is indicated, with surgical management reserved for severe damage.[7][Level of evidence: I] Fewer than 2% of the 5% to 15% of patients who received abdominal or pelvic radiation will require surgical intervention.[10]

    The timing and choice of surgical techniques remains somewhat controversial. A lower operative mortality (21% vs. 10%) and incidence of anatomic dehiscence (36% vs. 6%) have been reported with intestinal bypass as compared with resection.[11][Level of evidence: II][12] Those who favor resection point out that the removal of diseased bowel decreases the mortality rate for resection and is comparable to the bypass procedure.[11] All agree that simple lysis of adhesions is inadequate and that fistulas require bypass.

    Surgery should be undertaken only after careful assessment of the patient's clinical condition and extent of radiation damage because wound healing is often delayed, necessitating prolonged parenteral feeding after surgery. Even after apparently successful operations, symptoms may persist in a significant proportion of patients.[13]

    Prevention

    Treatment techniques that can minimize the risk of severe radiation enteritis include the following:

    1. Radiation therapy techniques, including the following:
      1. The use of a three- or four-field technique (as opposed to a two-field technique) to minimize the amount of small bowel exposed to treatment.
      2. The treatment of the patient in a physical position that will aid in removing as much small bowel from the treatment field as possible (e.g., treating a patient with a full bladder each day to aid in pushing the small bowel up and out of the pelvis when pelvic radiation is given).
      3. Daily treatment of all fields, resulting in a lower integral dose and more homogenous dose distribution.
      4. Use of computerized radiation dosimetry to best design the treatment plan and the use of high-energy treatment machines such as linear accelerators that deliver a high dose-to-tumor volume while sparing the normal structures.[14]
    2. Surgery. Placing clips in high-risk areas to better define the location or former location of the tumor and aid in radiation treatment planning.
    3. Modification of treatment sequencing. An area for exploration is the sequencing of radiation, chemotherapy, and surgery and its influence on the severity of enteritis.

    References:

    1. O'Brien PH, Jenrette JM 3rd, Garvin AJ: Radiation enteritis. Am Surg 53 (9): 501-4, 1987.
    2. Yeoh EK, Horowitz M: Radiation enteritis. Surg Gynecol Obstet 165 (4): 373-9, 1987.
    3. Gallagher MJ, Brereton HD, Rostock RA, et al.: A prospective study of treatment techniques to minimize the volume of pelvic small bowel with reduction of acute and late effects associated with pelvic irradiation. Int J Radiat Oncol Biol Phys 12 (9): 1565-73, 1986.
    4. Haddad GK, Grodsinsky C, Allen H: The spectrum of radiation enteritis. Surgical considerations. Dis Colon Rectum 26 (9): 590-4, 1983.
    5. Alimentary tract. In: Fajardo LF: Pathology of Radiation Injury. New York: Masson Publishers, 1982, pp 47-76.
    6. Yasko JM: Care of the Client Receiving External Radiation Therapy. Reston, Va: Reston Publishing Company, Inc., 1982.
    7. Stryker JA, Bartholomew M: Failure of lactose-restricted diets to prevent radiation-induced diarrhea in patients undergoing whole pelvis irradiation. Int J Radiat Oncol Biol Phys 12 (5): 789-92, 1986.
    8. Kinsella TJ, Bloomer WD: Tolerance of the intestine to radiation therapy. Surg Gynecol Obstet 151 (2): 273-84, 1980.
    9. Mendelson RM, Nolan DJ: The radiological features of chronic radiation enteritis. Clin Radiol 36 (2): 141-8, 1985.
    10. Galland RB, Spencer J: Surgical management of radiation enteritis. Surgery 99 (2): 133-9, 1986.
    11. Lillemoe KD, Brigham RA, Harmon JW, et al.: Surgical management of small-bowel radiation enteritis. Arch Surg 118 (8): 905-7, 1983.
    12. Wobbes T, Verschueren RC, Lubbers EJ, et al.: Surgical aspects of radiation enteritis of the small bowel. Dis Colon Rectum 27 (2): 89-92, 1984.
    13. Wellwood JM, Jackson BT: The intestinal complications of radiotherapy. Br J Surg 60 (10): 814-8, 1973.
    14. Minsky BD, Cohen AM: Minimizing the toxicity of pelvic radiation therapy in rectal cancer. Oncology (Huntingt) 2 (8): 21-5, 28-9, 1988.

    WebMD Public Information from the National Cancer Institute

    Last Updated: February 25, 2014
    This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information.
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